Cycle 1
Health 2025-06-18 · Fire 2025-06-18
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Muncie, IN
Westminster Village Muncie Inc
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5801 W Bethel Ave, Muncie, IN
(765) 288-2155
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1975-10-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.93
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.78
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
555
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
67.67
Composite VBP score used to determine payment impact.
Payment multiplier
1.0211
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.88
Baseline 17.83% · Performance 18.24% · Measure score 6.88 · Achievement 6.88 · Improvement 0
Healthcare-associated infections
7.39
Baseline 5.63% · Performance 5.63% · Measure score 7.39 · Achievement 7.39 · Improvement 0
Total nurse turnover
5.06
Baseline 27.54% · Performance 43.01% · Measure score 5.06 · Achievement 5.06 · Improvement 0
Adjusted total nurse staffing
7.73
Baseline 5 hours · Performance 5.28 hours · Measure score 7.73 · Achievement 7.73 · Improvement 3.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 255 · Observed rate 8.63% · Lower 95% interval 7.41% |
| Discharge to community | 66.4% |
50.57%
15.8 pts better
|
Better than the National Rate · Eligible stays 255 · Observed rate 66.27% · Lower 95% interval 59.4% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.52% |
95.27%
2.2 pts better
|
Numerator 118 · Denominator 121 |
| Falls with major injury | 2.48% |
0.77%
1.7 pts worse
|
Numerator 3 · Denominator 121 |
| Discharge self-care score | 53.76% |
53.69%
0.1 pts better
|
Numerator 50 · Denominator 93 |
| Discharge mobility score | 38.71% |
50.94%
12.2 pts worse
|
Numerator 36 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 0.83% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 121 · Adjusted rate 0.8% |
| Healthcare-associated infections requiring hospitalization | 5.63% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 3.07% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 1.72% |
8.2%
6.5 pts worse
|
Numerator 4 · Denominator 233 |
| Staff flu vaccination coverage | 11.44% |
42%
30.6 pts worse
|
Numerator 39 · Denominator 341 |
| Discharge function score | 43.01% |
56.45%
13.4 pts worse
|
Numerator 40 · Denominator 93 |
| Transfer of health information to provider | 79.31% |
95.95%
16.6 pts worse
|
Numerator 23 · Denominator 29 |
| Transfer of health information to patient | 96.1% |
96.28%
0.2 pts worse
|
Numerator 74 · Denominator 77 |
| Resident COVID-19 vaccinations up to date | 30.36% |
25.2%
5.2 pts better
|
Numerator 17 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.6
0.8 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
93.6%
4 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 97.5% · Q4 95.1% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.2% |
95.4%
2.2 pts worse
|
95.5%
2.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.1% |
3.8%
8.3 pts worse
|
3.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 14.6% · Q3 12.5% · Q4 4.9% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.5% |
24.6%
17.1 pts better
|
11.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.5% · Q3 5.0% · Q4 5.0% · 4Q avg 7.5% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
5.6%
0.9 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.9% · Q3 7.4% · Q4 0.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
23.5%
7.8 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 12.5% · Q3 17.2% · Q4 11.4% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.5% |
14.8%
11.3 pts better
|
16.7%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 9.4% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.7% |
13.3%
14.4 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.8% |
11.7%
19.1 pts worse
|
14.9%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 32.3% · Q3 24.1% · Q4 38.2% · 4Q avg 30.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.7% |
0.4%
8.3 pts worse
|
1.0%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 9.6% · Q3 8.5% · Q4 8.0% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.2%
0.6 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 39.4% |
24.2%
15.2 pts worse
|
19.8%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 53.8% · Q3 30.2% · Q4 50.3% · 4Q avg 39.4% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.1%
1.8 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 2.4% · Q3 8.7% · Q4 8.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.0% |
81.6%
8.4 pts better
|
81.7%
8.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 91.4% · Q3 90.0% · Q4 88.8% · 4Q avg 90.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
10.5%
6.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 3.8% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 1.5% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
79.0%
2.8 pts worse
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
22.4%
2.8 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 16.5% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-28 · Fire 2024-05-28
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-02-10 · Fire 2023-02-10
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-06-18
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-06-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-06-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-10
E · Potential for more than minimal harm
2024-05-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-05-28
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-06-25
E · Potential for more than minimal harm
2024-05-28
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-06-25
F · Potential for more than minimal harm
2023-02-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-10
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-02-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-02-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-06-18
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-06-18
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-06-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-08-07
D · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-07
C · Minimal harm
2025-06-18
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2025-08-07
D · Potential for more than minimal harm
2024-05-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-03-06
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-04-05
E · Potential for more than minimal harm
2023-02-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-03-13
D · Potential for more than minimal harm
2023-02-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-13
Penalties and ownership
What sits behind the stars
Ownership
Abbs, Jan
Corporate Director · Individual
Childs, Jerald
Corporate Director · Individual
Craig, Janice
Corporate Director · Individual
Crutcher, Mary
Operational/Managerial Control · Individual
Crutcher, Mary
Corporate Officer · Individual
Dawson, Andrew
Corporate Director · Individual
Ervin, Mark
Corporate Director · Individual
Farquher, Ronald
Corporate Director · Individual
Feick, Debbie
Corporate Director · Individual
First Merchants Bank
5% Or Greater Mortgage Interest · Organization
Forvis Mazars Llp
Operational/Managerial Control · Organization
Galliher, Michael
Corporate Director · Individual
Jones, Dustin
Corporate Officer · Individual
Kirkpatrick-Sikora, Magi
Corporate Director · Individual
Littler, John
Corporate Director · Individual
Matchett, Loren
Corporate Director · Individual
Scherrer, Eric
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Morrison Woods Health Campus
Muncie, IN
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Brickyard Healthcare - Muncie Care Center
Muncie, IN
2-star overall rating with 2-star inspections with $22,360 in total fines with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Bethel Pointe Health And Rehab
Muncie, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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